Neuropsychiatric Disease and Treatment
open access to scientific and medical research
Open Access Full Text Article
The major risk factors for delirium in a
clinical setting
Harin Kim
Seockhoon Chung
Yeon Ho Joo
Jung Sun Lee
Department of Psychiatry, Asan
Medical Center, University of Ulsan
College of Medicine, Seoul, Korea
Correspondence: Jung Sun Lee
Department of Psychiatry, Asan Medical
Center, University of Ulsan College
of Medicine, 88 Olympic-ro 43-gil,
Songpa-gu, Seoul 05505, Korea
Fax +82 2 485 8381
Email js_lee@amc.seoul.kr
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http://dx.doi.org/10.2147/NDT.S112017
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Original Research
This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment
21 July 2016
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Objective: We aimed to determine the major risk factors for the development of delirium in
patients at a single general hospital by comparison with a control group.
Subjects and methods: We reviewed the medical records of 260 delirium patients and 77 control
patients. We investigated age, sex, and risk factors for delirium in the total delirium group (n=260),
the delirium medical subgroup (n=142), and the delirium surgical subgroup (n=118). Logistic
regression analysis adjusting for age and sex was performed to identify the odds ratio.
Results: The mean age and the percentage of males were significantly higher in the delirium
group compared with the control group (68.9 vs 54.3 years and 70% vs 41.6%, respectively).
Risk factors for the delirium group were lower plasma albumin, hypertension, mechanical
ventilation, and antipsychotic drug use. Plasma sodium level and hypertension were important
risk factors for the delirium medical subgroup. Stroke history, hypertension, ICU care, and
medication were important risk factors for the delirium surgical subgroup.
Conclusion: Lower plasma albumin, hypertension, mechanical ventilation, and antipsychotic
drug use are important risk factors for delirium.
Keywords: delirium, acute confusional state, psychiatric consultation, risk factor
Introduction
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
defines delirium as a disturbance in attention and awareness over a short period of
time, representing a change from baseline attention and awareness, with a tendency to
fluctuate in severity during the course of a day.1 Delirium is a very common disorder
affecting ~15% of medical elderly inpatients.2 In a general population study, the preva-
lence of delirium was 1%–2% in subjects .65 years old and 10% in subjects .85 years
old.3 Patients with delirium have higher mortality and poor long-term prognosis.4,5 These
results are contrary to the common belief that delirium is a reversible condition and
suggest that active intervention should begin at diagnosis due to the adverse effects of
delirium on long-term functional outcomes.6–8 A recent systematic review of prospective
trials suggested that some pharmacological interventions, such as the use of haloperidol,
showed success in preventing delirium and in decreasing the duration and/or severity
of ongoing delirium, which is associated with better long-term outcomes.9
The most important aspect in the treatment and management of delirium is identify-
ing and correcting the underlying causes. The causes of delirium are old age, male sex,
underlying cognitive impairment,10,11 infection, fever,12,13 hypoxia, hypoglycemia, elec-
trolyte imbalance, general medical conditions such as cardiovascular, renal, and hepatic
diseases,14 use of drugs such as benzodiazepine and narcotic analgesics,15,16 metabolic
disorders such as encephalopathy, and central nervous system diseases such as stroke,
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Kim et al
traumatic brain injury, and epilepsy.17,18 In addition, major
surgical procedures such as orthopedic and cardiovascular
surgeries, conditions associated with major surgeries such
as somatic pain and cobalamin deficiency,19,20 and treatment
environments such as ICUs are known risk factors.21
Most previous studies have investigated individual risk
factors for delirium separately in their respective clinical situ-
ations. Accordingly, their subjects were limited to those with
specific diseases or treatments, and their outcomes identified
statistically significant risk factors for delirium.22–30 When the
results of these studies were compared with a meta-analysis
of the risk factors for delirium, some risk factors such as age
and the use of benzodiazepine were relatively consistent, but
others were not.31–33 For example, the presence of hyperten-
sion or hypoalbuminemia was not associated with delirium
in one prospective study, while other evidence suggests that
these factors are associated with delirium.14 Few studies have
comprehensively examined the reported risk factors, and no
study has examined their relative importance.
In this study, we investigated the risk factors for delirium
in patients referred for psychiatric consultation, diagnosis,
and management. We aimed to identify the risk factors for
inpatients who underwent a major surgery under general
anesthesia and patients who did not.
Subjects and methods
Subjects
We selected the delirium group and the control group from
among patients referred to psychiatrists from August 2013
to July 2014. The delirium group included patients who were
interviewed individually by psychiatrists and diagnosed with
delirium according to DSM-5 criteria. We excluded patients
whose cognitive impairments or psychiatric symptoms
were caused by a psychiatric or neurologic disease, such
as hallucination, delusion, or abnormal behavior caused by
schizophrenia or schizoaffective disorder, or mood symp-
toms resulting from major mood episodes. We also excluded
patients with Alzheimer’s disease, vascular dementia, or
dementia with Lewy bodies. Patients with substance use
disorder were excluded because they might have had a
cognitive impairment indistinguishable from delirium. The
control group was selected from among patients referred to
psychiatrists but not diagnosed with delirium.
Depending on the nature of the psychomotor disturbance
and DSM-5 specifier definition, delirium was classified as
follows: 1) hyperactive – increased psychomotor activity that
may be accompanied by mood lability, agitation, and/or refusal
to cooperate with medical care; 2) hypoactive – decreased
psychomotor activity that may be accompanied by
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sluggishness, lethargy, or stupor; or 3) mixed – normal psy-
chomotor activity with disturbed attention and awareness, or
rapid fluctuation between hyperactive and hypoactive states of
delirium.1 Patients were deemed to have psychotic symptoms
when further information from caregivers indicated that there
was evidence of hallucination or delusion.
The institutional review board of the Asan Medical Center
approved the study, including the data collection and analy-
sis. As this study was performed retrospectively, informed
consent was not considered necessary by the institutional
review board.
Methods
This study collected data from medical records written by
psychiatrists who evaluated the patients. The delirium group
was divided into medical and surgical subgroups, each of
which was compared with the control group. The delirium
medical subgroup included patients who were admitted
to the hospital but did not undergo surgery under general
anesthesia, while the delirium surgical subgroup included
patients who did undergo surgery under general anesthesia.
The overall severity of delirium was assessed by the Clinical
Global Impression-Severity (CGI-S) scale.
Age, sex, and risk factors for delirium were investigated
in the delirium and control groups. Risk factors consistently
found in previous studies were comprehensively included and
categorized by past medical history, treatment environment,
physical illness, and medication history. Past medical history
included delirium, dementia, stroke, gait disorder, falling,
neurologic diseases, and hypertension. In addition, alcohol
use within 1 week before delirium onset was noted, and activi-
ties of daily living (ADL) were evaluated on a four-point scale
using the caregiver interview conducted by a psychiatrist (1:
requires maximum aid for daily living; 2: requires moderate
aid; 3: requires minimum aid; 4: does not require aid).
Treatment environments included ICU treatment and
the preventive use of chemical or physical restraints before
the occurrence of delirium. Chemical restraint was defined
as intravenous or intramuscular injection of a benzodiaz-
epine or an antipsychotic drug, and physical restraint was
defined as restraint of the upper or lower limbs. Chemical or
physical restraint used for patient safety after the occurrence
of delirium was not included as a risk factor.
Physical illness included surgery under general anesthesia
after admission, use of mechanical ventilation, and infection.
Infection was defined by laboratory tests, the identification
of pathogens in bacterial culture, or the empirical use of
antibiotics. The patient was considered immobile if he or
she was unable to ambulate independently due to a physical
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impairment such as fracture or a neurological disease, or if
absolute bed rest was ordered by the medical staff. Renal
function was assessed by evaluating the blood urea nitrogen
(BUN) and plasma creatinine (CR) levels, and hepatic func-
tion was assessed by estimation of blood levels of aspartate
transaminase (AST) and alanine transaminase (ALT), as well
as plasma albumin levels. Electrolyte imbalance was assessed
by determining sodium and potassium levels.
For medication history, all drugs used within 3  days
before the occurrence of delirium were explored. The overall
number of medications was counted, and the use of antipsy-
chotic drugs, anticholinergic drugs, antiepileptic drugs, and
narcotic analgesics was investigated.
Statistical methods
We compared age, sex, prevalence of psychotic symptoms
manifested as hallucinations or delusions, and the frequency of
the delirium type between the delirium and control groups. We
tried to identify the potential risk factors for delirium in two
steps. In Step 1, we used Student’s t-tests or chi-square tests
for demographic and clinical variables. In Step 2, variables
with P,0.1 in Step 1 were entered into the next analysis of
multiple logistic regression. We identified the odds ratio (OR)
for each factor’s contribution to the occurrence of delirium
using multiple logistic regression analysis, with adjustment
for age and sex. Statistical analyses were undertaken using
SPSS version 18 (IBM Corporation, Armonk, NY, USA), and
a P-value ,0.05 was considered statistically significant.
Results
We included 260 patients in the delirium group and 77 patients
in the control group. Among the patients in the delirium group,
142 patients (54.6%) were classified into the delirium medical
subgroup and 118 patients (45.4%) into the delirium surgi-
cal subgroup. Most of the patients in the control group were
diagnosed with major depression, adjustment disorder, sleep
disorder, panic disorder, or unspecified anxiety disorder.
The mean age was 68.9  years (standard deviation
[SD]:  ±13.0  years) in the delirium group and 54.3  years
(SD:  ±16.8  years) in the control group. In addition, 182
patients (70%) in the delirium group and 32 patients (41.6%)
in the control group were male. The mean age of the delirium
group was significantly higher than that of the control group
(t=-8.05, P,0.001), and there were more male patients in
the delirium group than in the control group (70% vs 41.6%,
χ2=20.7, P,0.001). In the delirium group, 167 patients
(64.2%) had hyperactive delirium, 18 patients (6.9%) had
hypoactive delirium, and 75  patients (28.8%) had mixed
delirium. Regarding psychotic symptoms, 91 patients (35%)
Neuropsychiatric Disease and Treatment 2016:12
Determination of risk factors for delirium
experienced hallucination and 52 patients (20%) experienced
delusion. The mean severity was a Clinical Global Impression –
Severity scale (CGI-S) score of 4.0.
There were no significant differences in terms of age,
sex, type of delirium, frequency of psychotic symptoms,
or CGI-S score between the two subgroups. There was a
significant difference in age between the medical subgroup
(69.3±13.9 years, t=-7.06, P,0.001) and the surgical sub-
group (68.4±11.9 years, t=-6.86, P,0.001) compared with
the control group (54.3±16.8 years). There were more male
patients in the medical subgroup (70.4%, χ2=17.37, P,0.001)
and the surgical subgroup (69.5%, χ2=14.97, P,0.001) than
in the control group (41.6%) (Table 1).
In Step 1, we identified the potential risk factors by com-
parison with the control group: 1) By comparing the delirium
group with the control group, we could find out that ADL
score, the BUN, CR, and plasma albumin levels number of
medications, past history of delirium and stroke, ICU care,
hypertension, mechanical ventilation, infection, immobility,
and use of antipsychotic drugs were the potential risk factors of
delirium in the delirium group. 2) By comparing the delirium
medical subgroup with the control group, we could find out
that ADL score, the BUN, CR, plasma albumin, and plasma
sodium levels, past history of delirium and stroke, past history
of falls, hypertension, mechanical ventilation, infection, and
use of antipsychotic drugs were the potential risk factors of
delirium in the delirium medical subgroup. 3) By comparing
the delirium surgical subgroup with the control group, we
could find out that ADL score, the BUN, CR, and plasma albu-
min levels, number of medications, past history of delirium
and stroke, ICU care, hypertension, mechanical ventilation,
immobility, and the use of antipsychotic drugs, anticholinergic
drugs, and opioids were the potential risk factors of delirium
in the delirium surgical subgroup (Tables 2 and 3).
In Step 2, we identified the risk factors for delirium after
multiple logistic regression, after controlling for age and
sex (results are presented as OR, 95% confidence interval
[CI]): 1) In the delirium group, plasma albumin level (0.55,
0.32–0.94), hypertension (2.86, 1.21–6.72), mechanical
ventilation (12.49, 1.13–138.00), and use of antipsychotic
drugs (4.07, 1.41–11.72); 2) In the delirium medical sub-
group, plasma sodium level (0.90, 0.83–0.98) and hyper-
tension (2.91, 1.12–7.55); and 3) In the delirium surgical
subgroup, plasma albumin level (0.37, 0.16–0.87), number
of medications (1.09, 1.00–1.18), past history of stroke
(1,817.71, 5.37–614,920.5), ICU care (17.95, 1.96–164.55),
hypertension (5.90, 1.39–25.09), and the use of antipsychotic
drugs (14.57, 2.93–72.37), anticholinergic drugs (14.50,
1.57–134.14), and opioids (6.10, 1.58–23.44) (Table 4).
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Table 1 Characteristics of the delirium and control groups

Characteristics Delirium group Control P-value
Total Medical Surgical group Total vs Medical Surgical Medical
subgroup subgroup control subgroup subgroup subgroup
vs control vs control vs surgical
subgroup
Number of patients, n (%) 260 142 (54.6%) 118 (45.4%) 77 – – – –
Age, years, mean ± SD 68.9±13.0 69.3±13.9 68.4±11.9 54.3±16.8 t=-8.05; t=-7.06; t=-6.86; t=0.52;
P,0.001 P,0.001 P,0.001 P=0.603
Male sex, n (%) 182 (70.0%) 100 (70.4%) 82 (69.5%) 32 (41.6%) χ2=20.7; χ2=17.37; χ2=14.97; χ2=0.027;
P,0.001 P,0.001 P,0.001 P=0.87
Psychotic symptoms
Hallucination, n (%) 91 (35.0%) 47 (33.1%) 44 (37.6%) – – – – χ2=0.57;
P=0.449
Delusion, n (%) 52 (20.0%) 31 (21.8%) 21 (18.0%) – – – – χ2=0.603;
P=0.438
CGI-S score, mean ± SD 3.99±0.8 4.01±0.88 3.96±0.81 – – – – t=0.395;
P=0.693
Type of delirium
Hyperactive, n (%) 167 (64.2%) 90 (63.4%) 77 (65.3%) – – – – χ2=1.28;
Hypoactive, n (%) 18 (6.9%) 8 (5.6%) 10 (8.5%) – – – – P=0.526
Mixed, n (%) 75 (28.8%) 44 (31.0%) 31 (26.3%) – – – – –
Abbreviations: CGI-S, Clinical Global Impression – Severity scale; SD, standard deviation.

Discussion for delirium. However, this study was designed to identify

In this study, the mean age of the subjects in the delirium
group was 14.6  years, which was greater than that of the
control group, and 70% of the delirium group comprised
males, whereas only 41.6% of the control group were males.
This was concordant with previous reports that identified
age and male sex as the major risk factors for the develop-
ment of delirium.10,11,34 Age and sex, which are unmodifiable
through medical intervention, are demographic risk factors
the significant risk factors for delirium across a wide range
of clinical settings and to evaluate the OR of each risk fac-
tor. Therefore, we adjusted for age and sex in the logistic
regression in Step 2.
Among the psychomotor disturbance subtypes, hyperac-
tive delirium was the most common (64.2%), while hypo-
active delirium was the least common (6.9%). This result
contrasts with the general opinion that mixed delirium is the

Table 2 Comparison between delirium group and control group in terms of risk factors for delirium (continuous variables)
Risk factors Delirium group (n=260), mean ± SD Control Comparisons between delirium group
group (n=77), and control group (P-value)
Total Medical Surgical mean ± SD Total Medical Surgical
subgroup subgroup delirium subgroup subgroup
vs control vs control vs delirium
Past medical history
ADL score 3.2±0.9 3.03±1.01 3.4±0.80 3.7±0.6 0.0001 ,0.0001 0.0308
Physical illness
BUN (mg/dL) 24.1±15.0 24.8±15.0 23.2±15.0 18.3±13.8 0.0026 0.0018 0.0226
Creatinine (mg/dL) 1.6±1.9 1.7±2.0 1.5±1.7 1.1±1.1 0.0105 0.0059 0.0410
AST (IU/L) 46.4±91.6 42.8±42.4 50.8±128.0 46.0±66.3 0.9729 0.6596 0.7639
ALT (IU/L) 42.8±104.4 40.3±53.5 45.9±143.8 42.6±67.2 0.9871 0.7762 0.8508
Albumin (g/dL) 2.7±0.6 2.7±0.6 2.8±0.7 3.2±0.7 ,0.0001 ,0.0001 0.0001
Sodium (mmol/L) 136.7±10.0 135.5±12.5 138.1±5.4 138.5±4.2 0.1118 0.041 0.5230
Potassium (mmol/L) 4.1±0.6 4.1±0.7 4.1±0.6 4.2±0.6 0.2631 0.2779 0.3546
Medication history
Number of drugs 11.5±6.3 10.4±4.7 12.8±7.6 9.5±4.9 0.0093 0.1599 0.0008
Abbreviations: ADL, activities of daily living; BUN, blood urea nitrogen; AST, aspartate transaminase; ALT, alanine transaminase; SD, standard deviation.

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Dovepress Determination of risk factors for delirium

Table 3 Comparison between delirium group and control group in terms of risk factors for delirium (categorical variables)
Risk factors Delirium group (n=260), n (%) Control, Comparisons between delirium group
n (%) and control group (P-value)
Total Medical Surgical Total Medical Surgical
subgroup subgroup delirium subgroup subgroup
vs control vs control vs control
Past medical history
Past delirium history 59 (22.7) 26 (18.3) 33 (28.0) 4 (5.2) 0.001 0.007 ,0.001
Dementia history 10 (3.9) 5 (3.5) 5 (4.2) 1 (1.3) 0.269 0.336 0.245
Stroke history 26 (10) 10 (7.04) 16 (13.56) 1 (1.3) 0.013 0.063 0.003
Ambulation difficulty 42 (16.2) 24 (16.9) 18 (15.3) 8 (10.4) 0.211 0.193 0.329
Falling history 18 (6.9) 13 (9.15) 5 (4.24) 2 (2.6) 0.158 0.067 0.547
Past neurologic history 39 (15.0) 23 (16.2) 16 (13.6) 11 (14.3) 0.877 0.709 0.886
Hypertension 124 (47.7) 67 (47.2) 57 (48.3) 12 (15.6) ,0.001 ,0.001 ,0.001
Alcohol use 9 (3.5) 3 (2.1) 6 (5.1) 3 (3.9) 0.857 0.440 0.699
Treatment environment
ICU care 66 (25.4) 29 (20.4) 37 (31.4) 9 (11.7) 0.011 0.103 0.002
Chemical restraint 76 (29.2) 38 (26.8) 38 (32.2) 0 (0) ,0.001 ,0.001 ,0.001
Physical restraint 49 (18.9) 21 (14.8) 28 (23.7) 0 (0) ,0.001 ,0.001 ,0.001
Physical illness
Surgery 118 (45.4) 0 118 (100) 13 (16.9)
Mechanical ventilation 34 (13.1) 20 (14.1) 14 (11.9) 1 (1.3) 0.003 0.002 0.007
Infection 122 (46.9) 83 (58.5) 39 (33.1) 18 (23.4) ,0.001 ,0.001 0.147
Immobility 92 (35.4) 48 (33.8) 44 (37.3) 8 (10.4) ,0.001 ,0.001 ,0.001
Medication history
Antipsychotic drug use 102 (39.2) 50 (35.2) 52 (44.1) 6 (7.8) ,0.001 ,0.001 ,0.001
Anticholinergic drug use 26 (10.0) 9 (6.3) 17 (14.4) 4 (5.2) 0.193 0.732 0.043
Anticonvulsant use 24 (9.2) 11 (7.8) 13 (11.0) 5 (6.5) 0.452 0.734 0.286
Opioid use 126 (48.5) 59 (41.6) 67 (56.8) 33 (42.9) 0.387 0.851 0.057
Abbreviation: ICU, intensive care unit.

Table 4 Multiple logistic regression of risk factors for delirium

Risk factors Total delirium vs control Medical subgroup vs control Surgical subgroup vs control
OR 95% CI P-value OR 95% CI P-value OR 95% CI P-value
Past medical history
Past delirium history 2.90 0.90–11.97 0.142 3.68 0.62–21.70 0.150 7.47 0.87–63.87 0.066
Past history of stroke 8.98 0.48–168.04 0.142 3.19 0.08–121.62 0.533 1,817.71* 5.37–614,920.5 0.012
Past history of falls – – – 0.98 0.14–6.99 0.981 – – –
Treatment environment
ICU care 1.82 0.56–5.92 0.321 – – – 17.95* 1.96–164.55 0.011
Hypertension 2.86* 1.21–6.72 0.016 2.91* 1.12–7.55 0.028 5.90* 1.39–25.09 0.016
Mechanical ventilation 12.49* 1.13–138.00 0.039 10.04 0.97–104.21 0.053 6.80 0.29–157.28 0.232
Infection 2.01 0.87–4.63 0.103 2.49 0.98–6.33 0.055 – – –
Immobility 2.61 0.90–7.55 0.077 2.92 0.88–9.71 0.080 2.12 0.40–11.15 0.375
Physical illness
ADL score 0.86 0.52–1.42 0.554 0.67 0.37–1.18 0.165 0.79 0.39–1.61 0.518
BUN 1.00 0.97–1.03 0.997 1.01 0.98–1.04 0.561 1.00 0.94–1.05 0.855
CR 1.15 0.813–1.64 0.422 1.13 0.80–1.61 0.479 0.92 0.53–1.61 0.782
Albumin 0.55* 0.32–0.94 0.028 0.63 0.33–1.21 0.165 0.37* 0.16–0.87 0.022
Sodium – – – 0.90* 0.83–0.98 0.010 – – –
Medication history
Number of medications 1.06 0.99–1.15 0.1 – – – 1.09* 1.00–1.18 0.050
Antipsychotic drug use 4.07* 1.41–11.72 0.009 2.38 0.73–7.81 0.151 14.57* 2.93–72.37 0.001
Anticholinergic drug use – – – – – – 14.50* 1.57–134.14 0.018
Opioid use – – – – – – 6.10* 1.58–23.44 0.009
Note: *P,0.05.
Abbreviations: ADL, activities of daily living; BUN, blood urea nitrogen; CI, confidence interval; CR, creatinine; ICU, intensive care unit; OR, odds ratio.

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Kim et al
most common delirium subtype.35 This discrepancy may be
due to the fact that hypoactive delirium is difficult for medical
staff to identify and is easily missed. The natural course of
delirium fluctuates, and assessment is often made when the
symptoms have become aggravated, leading to a determina-
tion of hyperactive delirium. According to a recent study,36
one of the major reasons that nurses fail to detect delirium
is that the natural course of delirium changes. Because we
included patients who had been referred to psychiatrists, there
was a greater chance of including patients whose behavioral
problems were relatively severe and easily noticeable.
In order to identify the risk factors in two major clinical
situations, we categorized the delirium group into medical
and surgical subgroups. Lower albumin level, hypertension,
mechanical ventilation, and use of antipsychotic drugs were
identified as risk factors in the delirium group. Among these
factors, lower albumin level, hypertension, and use of antip-
sychotic drugs are modifiable through proper medical care,
and it might be important to correct these risk factors aggres-
sively to prevent and/or manage delirium. A recent meta-
analysis determined that the risk of delirium can be lowered
in surgical inpatients by the preventive use of antipsychotic
drugs.37 However, the use of antipsychotic drugs did not have
a significant effect on the duration of delirium, the severity
of symptoms, or the length of hospital stay.37 In contrast,
another study reported that the use of antipsychotic drugs in
ICU patients without a specific diagnosis might increase the
duration of hospital stay and mortality.38 Clearly, the effect of
antipsychotic drugs on delirium requires further research.
When we identified the risk factors for delirium in the
two subgroups, there were some differences. While the risk
factors in the medical subgroup were lower plasma sodium
level and hypertension, the risk factors in the surgical subgroup
were lower plasma albumin level, past history of stroke, ICU
care, hypertension, number of medications, and the use of
antipsychotic drugs, anticholinergic drugs, and opioids. The
fact that the two subgroups showed different results suggests
that different risk factors should be considered in each clinical
situation. For nonsurgical patients, it might be important to
control electrolyte imbalance. For surgical patients, surgery
is a known risk factor for delirium, and delirium is believed
to be associated with preoperative and postoperative stroke
in patients with risk factors for cardiovascular diseases.39–42
Furthermore, postoperative surgical patients are often treated in
the ICU, which itself is a risk factor for delirium. Thus, stroke
prevention should be a priority in surgical management.
This study had several limitations of note. First, we could
not clarify the temporal relation between risk factors and the
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occurrence of delirium because of the cross-sectional study
design. However, this limitation was minimized by the fact
that we collected the risk factor information prior to the onset
of delirium. Second, the etiology of delirium is multifactorial
and has not been completely clarified. In addition to the risk
factors included in this study, there might be unidentified or
inconsistently reported risk factors that were not included.
Because we could not process the information about medica-
tion use appropriately, the effect of medication history on the
development of delirium might have been underestimated.
Third, the control group and the delirium group were not
precisely matched. There were differences in physical illness
and major procedures such as surgery under anesthesia. It
was difficult to enroll matched controls who had no psychi-
atric problems and, accordingly, to obtain information from
psychiatric assessments for them. To reduce the effect of the
control group differences, however, we excluded certain risk
factors. For example, we excluded the use of benzodiazepines
in the analysis as we were certain that the control group had
a higher rate of use. Nevertheless, the results should be cau-
tiously interpreted. Fourth, because the number of patients
involved in our study is limited, it is difficult to extrapolate the
results to the general population. Moreover, some risk factors
(mechanical ventilation and past history of stroke) showed
wide CI of the ORs. It may be due to the small number of
patients who had risk factors. The results with wide CI should
be cautiously interpreted because these results may lose their
statistical significance in other studies.
We attempted to overcome the limitations of previous
studies by including various risk factors of delirium. We were
able to identify significant risk factors under general clinical
situations, ie, the study was not limited to one specific clinical
setting. Furthermore, we investigated both the delirium group
and the control group for the same risk factors. The use of the
control group for the analysis is one strength of our study.
Disclosure
The authors report no conflicts of interest in this work.
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